Untreated surgical conditions in Malawi: A randomised cross-sectional nationwide household survey

Background Noncommunicable diseases, such as surgical conditions have received little attention from public health planners in low income countries (LIC) like Malawi. Though increasingly recognised as a growing global health problem, the burden of surgical pathologies and access to surgical care has not been adequately identified in many LIC. Information on the spectrum and burden of surgical disease in Malawi is important to uncover the unmet need for surgery and for planning of the National Health Service.Methods This was a multistage random cluster sampling national survey. Households were selected from clusters using probability proportional to size method. 1448 households and 2909 interviewees were analysed. The Surgeons Overseas Assessment of Surgical need (SOSAS) tool was used to collect data. This electronic tablet based questionnaire tool included general information and a dual personalised head to toe inquiry on surgical conditions. The general information included number of household members, and inquired on any death within the past twelve months, and if any of the deaths in the family had a suspected surgical condition leading to that death. Data was collected by specially trained third year medical students.Results Out of 1480 selected households, 1448 (98%) agreed to participate, with 2909 interviewed individuals included in the study. The median household size was 6 individuals (range 1 – 47). Median age of interviewed persons was 35 years (range 0.25 – 104 years). 1027 out of 2909 (35%) of the interviewed people reported to be living with a condition requiring surgical consultation or intervention, whereas 146 of 616 (24%) of the total deaths reported to have occurred in the preceding 12 months were reported to have died from a surgically related condition. Most individuals did not seek health care due to lack of funds for transportation to the health facility. Only 3.1% of those that reported a surgical condition had surgical intervention.Conclusions There is a large unmet need for surgical care in Malawi. A third of the population is living with a condition needing surgical consultation or intervention, and a quarter of all deaths are potentially avoidable with surgery. Urgent scale up of surgical services and training are needed to reduce this huge gap in public health planning in the country

Validation of Chichewa short musculoskeletal function assessment (SMFA) questionnaire: A cross-sectional study

Background: The Short Musculoskeletal Function Assessment (SMFA) tool measures function and quality of life in patients with musculoskeletal conditions. Objective: This study aimed to translate and adapt culturally the SMFA into Chichewa, and assess its clinimetric properties. Methods: The translated Chichewa version was administered to 53 patients with musculoskeletal disorders. To assess repeatability, an additional 20 patients answered the questionnaire twice over a time interval of two weeks. Internal consistency, floor and ceiling effects, and repeatability were tested; construct validity was assessed with the World Health Organization Quality of Life Assessment tool (WHOQOL-BREF). Results: There was good internal consistency for both Dysfunction and Bothersome indices (Cronbach’s alpha 0.90) and good construct validity between both indices with the WHOQOL-BREF. Pearson’s correlation coefficient and intraclass correlation coefficient (ICC) for repeatability for the Dysfunction Index were 0.941 and 0.922 (95% CI: 0.772, 0.971) respectively, and 0.877 and 0.851 (95% CI: 0.629, 0.941) for the Bothersome Index respectively. Conclusion: The translated Chichewa SMFA is a valid tool for populations that speak the Chichewa language.publishedVersio

Validation and reliability of the Chichewa translation of the EQ-5D quality of life questionnaire in adults with orthopaedic injuries in Malawi

Background: The EQ-5D is a standardised instrument that measures health-related quality-of-life and explores cost-effectiveness of treatments. Malawi is a low-resource country that would benefit from assessment of quality-of-life among individuals living with chronic conditions. Chichewa is the official native language of Malawi. The Chichewa version of the EQ-5D-3L developed by EuroQoL group has not been validated with Chichewa speakers. The purpose of this study was to evaluate the clinimetric properties of the Chichewa EQ-5D-3L.Methods: Patients with orthopaedic conditions were recruited in the outpatient orthopaedic clinics and wards at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifty-three patients with various musculoskeletal problems were administered the Chichewa EQ-5D-3L and World Health Organization quality of life (WHO-QOL) questionnaires. To assess repeatability, a separate test–retest population of 20 patients were also selected from orthopaedic clinics and wards to fill out the questionnaire twice.Results: Convergence validity was determined, with each of the WHO-QOL domains and the EQ-5D descriptive index and visual analogue scale (VAS) having good to moderate correlation (r = 0.3–0.7). Internal consistency was measured for the descriptive index, and the Cronbach’s alpha was 0.7. The ceiling effect for the descriptive index and the VAS were 9.4% and 0%, respectively. No respondents reached floor effect for the descriptive index or the VAS. The test retest intraclass correlation coefficient reliability at 14 days was 0.984 for the VAS and 1 for the descriptive index, with all 20 respondents providing the same responses.Conclusions: The EuroQoL translated version of the Chichewa EQ-5D-3L was found to demonstrate adequate validity, internal consistency, floor/ ceiling effects, and reliability

Cost utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi

Background and purpose — In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST. Patients and methods — This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty. Results — Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66–0.76) and 0.77 (CI 0.71–0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer’s perspective, or$1,035 from the societal perspective. Interpretation — IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.publishedVersio

Impact of infection with human immunodeficiency virus-1 (HIV) on the risk of cancer among children in Malawi - preliminary findings

<p>Abstract</p> <p>Background</p> <p>The impact of infection with HIV on the risk of cancer in children is uncertain, particularly for those living in sub-Saharan Africa. In an ongoing study in a paediatric oncology centre in Malawi, children (aged ≤ 15 years) with known or suspected cancers are being recruited and tested for HIV and their mothers or carers interviewed. This study reports findings for children recruited between 2005 and 2008.</p> <p>Methods</p> <p>Only children with a cancer diagnosis were included. Odds ratios (OR) for being HIV positive were estimated for each cancer type (with adjustment for age (<5 years, ≥ 5 years) and sex) using children with other cancers and non-malignant conditions as a comparison group (excluding the known HIV-associated cancers, Kaposi sarcoma and lymphomas, as well as children with other haematological malignancies or with confirmed non-cancer diagnoses).</p> <p>Results</p> <p>Of the 586 children recruited, 541 (92%) met the inclusion criteria and 525 (97%) were tested for HIV. Overall HIV seroprevalence was 10%. Infection with HIV was associated with Kaposi sarcoma (29 cases; OR = 93.5, 95% CI 26.9 to 324.4) and with non-Burkitt, non-Hodgkin lymphoma (33 cases; OR = 4.4, 95% CI 1.1 to 17.9) but not with Burkitt lymphoma (269 cases; OR = 2.2, 95% CI 0.8 to 6.4).</p> <p>Conclusions</p> <p>In this study, only Kaposi sarcoma and non-Burkitt, non-Hodgkin lymphoma were associated with HIV infection. The endemic form of Burkitt lymphoma, which is relatively frequent in Malawi, was not significantly associated with HIV. While the relatively small numbers of children with other cancers, together with possible limitations of diagnostic testing may limit our conclusions, the findings may suggest differences in the pathogenesis of HIV-related malignancies in different parts of the world.</p

Associations between Burkitt Lymphoma among Children in Malawi and Infection with HIV, EBV and Malaria: Results from a Case-Control Study

Background: Burkitt lymphoma, a childhood cancer common in parts of sub-Saharan Africa, has been associated with Epstein Barr Virus (EBV) and malaria, but its association with human immunodeficiency virus (HIV) is not clear.Methodology/Principal Findings: We conducted a case-control study of Burkitt lymphoma among children (aged <= 15 years) admitted to the pediatric oncology unit in Blantyre, Malawi between July 2005 and July 2006. Cases were 148 children diagnosed with Burkitt lymphoma and controls were 104 children admitted with non-malignant conditions or cancers other than hematological malignancies and Kaposi sarcoma. Interviews were conducted and serological samples tested for antibodies against HIV, EBV and malaria. Odds ratios for Burkitt lymphoma were estimated using unconditional logistic regression adjusting for sex, age, and residential district. Cases had a mean age of 7.1 years and 60% were male. Cases were more likely than controls to be HIV positive (Odds ratio (OR)) = 12.4, 95% Confidence Interval (CI) 1.3 to 116.2, p = 0.03). ORs for Burkitt lymphoma increased with increasing antibody titers against EBV (p = 0.001) and malaria (p = 0.01). Among HIV negative participants, cases were thirteen times more likely than controls to have raised levels of both EBV and malaria antibodies (OR = 13.2; 95% CI 3.8 to 46.6; p = 0.001). Reported use of mosquito nets was associated with a lower risk of Burkitt lymphoma (OR = 0.2, 95% CI, 0.03 to 0.9, p = 0.04).Conclusions: Our findings support prior evidence that EBV and malaria act jointly in the pathogenesis of Burkitt lymphoma, suggesting that malaria prevention may decrease the risk of Burkitt lymphoma. HIV may also play a role in the etiology of this childhood tumor

The cost-effectiveness of orthopaedic clinical officers in Malawi

Background In Malawi the orthopaedic clinical officer (OCO) training programme trains non-physician clinicians in musculoskeletal care. We studied the cost-effectiveness of this program. Methods Hospital logbooks were reviewed for data pertaining to activity in seven district hospitals over a 6-month period. The total costs were divided by the total effectiveness, calculated as disability adjusted life years (DALYs) averted. Results The total cost-effectiveness of providing orthopaedic care through the OCO training programme was US$92.06 per DALY averted. The mean per hospital was US$138.75 (95% CI: US$69.58–207.91) per DALY averted which is very cost-effective when compared with other health interventions. Of the 837 patients treated 63% were aged &lt;15 years and 36% were in the ‘economically active’ demographic of ages 15–74 years. Conclusion Training of clinical officers in orthopaedic surgery is very cost-effective and allows transfer of skills into rural areas. The demographics suggest that failure to provide such care would have a negative economic impact. </jats:sec

Ward round - Crocodile bites in Malawi: microbiology and surgical management

We present a case series of 5 patients admitted over 5 months to Queen Elizabeth Central Hospital who had sustained injuries from a crocodile bite. Three patients required amputation of a limb. The severe soft tissue injury associated with a crocodile bite and the unusual normal oral flora of the crocodile create challenges in treatment. Progressive tissue destruction and haemolysis are complications of such infected wounds. An antibiotic regime is recommended that covers gram negative rods, anaerobes and may include doxycycline, as well as the need to have a low threshold for early amputation

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi

Background and purpose — Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods — Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results — Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation — Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN